Analysis of an Aa Recovery Story: It Might Have Been Worse

Social Influence:
High parental expectations: were put on him: “the ambition to succeed was instilled in me.” Having idealised his family (a “fine” one), he followed what they told and showed him, and from early age, worked in all his spare time, after school and during vacations as he took on his parents’ motto, “Keep busy; always have something constructive to do.” This continued in adult age when he kept busy and endeavouring to go up the ladder of professional success. Through his hard working he became director of a large bank. As his family was quite community-oriented, so was he, and he also became director of several civic organisations. Social compliance: When his work led him into more and more social activities, he observed his friends who seemed to drink without harmful consequences. With his sense of belonging, his desired outcome was to be similar to friends as an important trait of his personality was that he “disliked being different”. First he had friends in his group membership of leisure activities; later on, he had drinking friends, for whose company he neglected his children.

Progression of addictive behaviour:
Quantities and frequency: He started by drinking occasionally, while enjoying golf-playing, cocktail hour, good news or after hard days, worries or pressures. Then drinking became substitute to other pleasures and excessive. His social and leisure activities, golf, hunting and fishing took second place to it. He went on to morning drinks, “at first just two, then gradually more.” Drinking became prevalent. Obsession: “Drink planning became more important than any other plans.” Alcohol was the priority in his life. Plagued with tension, feelings of humiliation, guilt, remorse, anxiety, depression, helplessness, he was desperate with the emotional torture. “Hangovers were always with me… cold sweats, jumpy nerves, lack of sleep”…

Out of control behaviour:
Neglect of responsibilities in favour of drinking: He became careless, sometimes returning to work when he shouldn’t have, showing how disoriented he was. He worried his business associates. He humiliated his children who stopped bringing friends home, and his wife who threatened to leave him. Invitations to socialise with friends became fewer. He was hurting his family, work colleagues and friends in order to be able to drink as much as possible. Sometimes he would wake up after blackouts, not knowing how he’d got back home, realizing he had driven his car. “I was living in constant fear that I would get caught while driving…Blackouts were a constant worry.” He made many failed attempts to stop, and broken promises. Attempts at concealing drinking: he would go to places where he would be (or believed he would be as later on he realised people knew about his alcoholism) anonymous, sneaking drinks, making excuses to go out, etc… “The next steps were bottle hiding and excuses for trips in order to drink without restraint.”

Recovery:
Change: Rock bottom followed a family crisis and an ultimatum issued by his daughter, “It’s AA – or else!” In the AA program, his emotions changed to hope and relief, his behaviour to ‘getting active’ helping, which he reckons suited him well, taking back his pre-drink community responsibilities, etc. Spirituality: He went for the AA program without reservations, doing all he was told. There his conformism served him well. He made the observation that to refuse the spiritual program would be the consequence of a prejudice: “The fact that AA is a spiritual program didn’t raise any prejudice in my mind. I couldn’t afford the luxury of prejudice.”

APPLICATION OF THEORIES

Social Learning Theory

Social Influence. As in the process noted by A. Bandura (1977), this man learned by observing and imitating his parents, paying attention to them as models. Retaining information, he was capable of imitating early in life, getting “work of all kinds after school and during vacations”. While working at them he tried to find what would appeal to him as a life work, showing he had the internal motivation to do those jobs. Conditioned early to work hard, he became director of a large bank and director in “many important institution having to do with civic life.” Once his ambitions achieved, he started observing his friends – learning through modelling – seeing them drinking without apparent bad consequences. He joined the drinking occasionally, then daily, the combined enjoyment of company and alcohol having had a positive reinforcing effect. “Positive reinforcing effects are critical for establishing self-administration behavior, which leads to the hypothesis that positive reinforcement is the key to drug dependence” (Wise, 1988).

Progression of addictive behaviour: Drinking became associated with the positive reinforcing effect of the social reward and pleasure of playing golf with friends and sharing cocktail hour. Drinking, first conditioned by those associations, became the main element of reward, and the social activities became excuses for drinking. It is probable that his high position and demanding work involved stress. “If these stressful occasions of use become frequent enough, it is likely that an alcohol use disorder will develop.” (Maisto, Carey, and Bradizza, 1999). He drank as a response to emotional upsets, to stressful situations (hard day at work, worries, etc.), and was negatively reinforced by them. He describes the vicious cycle of withdrawals bringing fear and tension, causing him to use for immediate relief, negatively reinforcing his drinking. “While initial drug use may be motivated by the positive affective state produced by the drug, continued use leads to neuroadaptation to the presence of drug and to another source of reinforcement, the negative reinforcement associated with relieving negative affective consequences of drug termination.” (Russell, 1976). More stress came with fears that blackouts caused.

Out of control behaviour: He learned to conceal drinking from negative reinforcement, to avoid his friends and wife’s reactions. His addictive behaviours were probably reinforced by his wife empty threats to leave.

Recovery: When he did get into AA recovery, he learned by observing and imitating, doing everything he was told. From his first meeting with an AA member, he learned by modelling and vicarious experience, as well as cognitively.

Self-Efficacy
Social influence. It is likely that this man’s early experiences of work and the observation of his family’s ambitions contributed to his self-efficacy in his “ambition to succeed”, resulting in great success in his work life.

Progression of addictive behaviour: “Frequently addictive behaviours are exhibited under conditions perceived as stressful.” His self-efficacy level was likely to have lowered with his failed attempts at stopping. They could have brought on an Abstinence Violation Effect (AVE) as described in Marlatt and Gordon’s (1980, 1985).

Out-of-control behaviour: “People fear and avoid threatening situations they believe exceed their coping abilities.” That man developed his hiding behaviours as a consequence of situations he expected not to be able to cope with.

Recovery: “Situational factors affect substance use” (Maisto, Carey and Bradizza, 199, p.118): the situation of ruined birthday party and daughter’s ultimatum caused the rock bottom and the final decision to stop the drinking. Goldman, Del Boca and Darkes (1999) argue that “expectancies have a causal (mediational or process) influence on drinking”. That man’s expectancies changed, following the AA program, “It was a great relief to know I didn’t have to drink any more”. He stopped expecting he would have to as he had been before.

Self-Control Theories

Self-Regulation:
Social compliance: Gailliot et al. (2007), cited in A. C. Moss and K.R. Dyer, gave support to that theory demonstrating that “our ability to exercise self-control may be linked to blood glucose levels”. That man’s energy was depleted at the end of the day, and following Sokoloff’s notion (1973), his brain most likely lacking energy at cocktail hour, socialising hour. Progression of addictive behaviour: Baumeister (2003) “self-regulation operates as a limited resource, akin to strength or energy, especially insofar as it becomes depleted after use–leaving the depleted self subsequently vulnerable to impulsive and undercontrolled behaviors (including increased consumption of alcohol)”. This fits well with the description of the development of the addictive behaviour of that man. As the director of a large bank and of several civic institutions, it can be assumed that he was in a high-pressured job.

“People in high-pressured jobs can become ‘functioning alcoholics’.” So he was, at least for a sustained period of his addiction, able to regulate his behaviour during the day while he worked. Then, as described in Baumeister’s theory, his resource of energy becoming depleted at the end of the day, after work he became unable to continue to regulate it, so his drinking developed more and more as he wasn’t able to regulate his intake. The development of that man’s alcoholism fits in with Baumeister’s theory that “the development of addictive behaviour may involve a gradual reduction in one’s ability to exercise control.” Out-of-control behaviour: As self-regulation is an ability to inhibit inappropriate responses and to activate appropriate responses, it does show in this man’s careless ness at work, with family responsibilities and in blackouts. His behaviour became out of character as he’d been so responsible up to the time addiction took over his life.

Inhibitory Dysregulation
According to that theory, chronic use of drugs or alcohol effects neurological damage in the orbito-frontal cortex and the anterior cingulated cortex. Those parts of the brain are in the reward system; they reduce the ability to inhibit rewarding behaviours. This does not account for the social influence theme in this man’s life but it does for the progression of his addiction, as he became less and less able to inhibit the drinking behaviour while he got the reward of pleasure or the reducing of his stress. That part of the brain is also affected in some other disorders of compulsive behaviour such as OCD patients (Modell et al., 1992).

When they are affected, there is difficulty inhibiting certain thoughts and inappropriate behaviours. Lubman, Yücel and Pantelis (2004) explain thus that “some addicted individuals are unable to control their drug use when faced with potentially disastrous consequences” That would account for out-of-control behaviours such as going back to drinking even though his physical and mental health were deteriorating, he was threatened to lose his wife and family life, etc. However if, as the theory warrants, the decision making is damaged as impulsive responses cannot be easily controlled, the recovery stage is not accounted for, unless there could be spontaneous instant healing, as in that case the man made a very good decision after having those centres impaired.

Comparing and contrasting theories

The Social Learning Theory is the one which can account for most of that man’s story. The theme of hard work learned from the parents by observation and imitation is consistent with it. Self-Efficacy goes with it: built in childhood with experiences of diverse jobs was the expectancy of success that went along with his ambition. The four SLT defined by Bandura (1969) are present in that man’s story (cited in Psychological Theories of Drinking and Alcoholism, p.113): 1) differential reinforcement: the stimulus condition being the setting of pleasant circumstances as golf, fishing, etc…; 2) vicarious learning: by observation of others. Modelling is a “major source of acquisition of drinking patterns”. The observation of his friends drinking without apparent harm was enough to override his previous opinion against drinking 3) cognitive processes: expectancies of behavioural outcomes of pleasure with friends and activities. 4) reciprocal determinism: “As the individual changes his behaviour, the environment changes in response which in turn affects the individual’s future behaviour.” It is seen in his hiding behaviour and going to trips, etc. as a reaction to having been caught drinking by his wife; he would plan trips just to be able to drink freely.

His tongue-in-cheek joke about his wife getting “more narrow-minded” was probably how he perceived her when he was in active addiction. And in fact she also likely became more tense and fearful too, this in turn would have caused him to react in drinking even more. Bandura (1969) “emphasizes stress reduction as a major pharmacological action of alcohol and, therefore, as a major agent of negative reinforcement.” However the SLT does not completely apply to the sudden AA recovery. Arguably there could have been some (hidden?) learning happening during the active addiction, through the negative consequences, which finally led to the decision to give up but it doesn’t account for the sudden absence of withdrawals and the “knowing” that he wouldn’t need to drink any more. However, the continuation of recovery is consistent with Marlatt and Gordon’s idea (1985) that “The acquisition of cognitive strategies in a self-management program can result in changes in addictive behaviour to new, more adaptive behaviour coming under the control of cognitive processes of awareness and decision making.” That was this man’s case in AA. Self-Efficacy was defined by DiClemente, Prochaska and Gibertini (1985) as “the degree to which one feels competent or capable of performing an action”.

As a cognitive process, it is likely be a conscious process. That man’s self-efficacy might have been high concerning his work life but as his drinking progressed it became low concerning his ability to cope with stressful situation, so he drank on them. “Bandura hypothesized that alcohol problems resulted at least partly from deficits in skills to manage or cope with stressful events without the use of alcohol.” Then alcohol becomes a stressor itself. The memory of the stress seems to be taken away at first but the effects of drinking become stressing in themselves, hence the ‘reciprocal determinism’. The stress reduction effect does not last with the effects of alcohol. It is like a mirage which grows as stresses grow with alcohol use. Expecting he was not going to be able to cope with situations (such as facing his family) resulted in maladaptive coping behaviours (such as planning trips to drink). Self-Efficacy does not account for the sudden stop in drinking as recovery happened when it was probably at its lowest point. When an individual decides to take on the AA program, or even any program of recovery, he/she can often be at their lowest level of Self-Efficacy.

The Self-Regulation Theory involves processes that are not conscious like Self-Efficacy does. The failure to inhibit inappropriate responses can happen totally out of the awareness of the person. What an individual does during blackouts is a good example of that. It means the person won’t be able to activate appropriate responses. It fails to explain the sudden recovery and change the subject had when he accepted the AA program: he had just had his rock bottom and according to that theory, he would have run out of mental energy and been unable to activate the appropriate response he then had. It could be argued though that at that point he could have become aware of his inability to regulate himself to the point that he gave up trying and let his family and consequently his AA friends make the decisions for him.

The Inhibitory Dysregulation Theory: mostly applies at the developmental stage, when the brain reward pathway is gradually changed, and the addiction “turbo charges” it. It also accounts for the progression on quantity and frequency and the out of control behaviour, in particular the obsession side of it, with the difficulties inhibiting thoughts of drinking and planning to drink. The obsessive and compulsive side of alcoholism is very close to OCD’s in which those same centres are affected. However as for the three other theories examined here, it fails to account for the instant stopping and the AA recovery.

REFERENCES

Bandura, A. (1977), cited in T. Moss and K. R. Dyer, Psychology of Addictive Behaviour, 2010, Palgrave Macmillan, Basingstoke. Ch.3, p. 64.

Baumeister R. F. (2003) Ego Depletion and Self-Regulation Failure: A Resource Model of Self-Control ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH Vol. 27, No. 2 February 2003 Cleveland, Ohio.

DiClemente, Prochaska and Gibertini (1985), Self-Efficacy and the stages of self-change of smoking. Cognitive Therapy and Research, 9, 181-200 (in T. Moss and K. R. Dyer, Psychology of Addictive Behaviour, Ch 3. 2010, Palgrave Macmillan, Basingstoke.)

Einstein A. (viewed on 12 March 2012 at:)
http://thinkexist.com/quotation/nothing_truly_valuable_arises_from_ambition_or/145959.html

Gailliot et al. (2007), cited in A. C. Moss and K.R. Dyer. Psychology of Addictive Behaviour, 2010, Palgrave Macmillan, Basingstoke, Ch.4. p.71.

Goldman M. S., Del Boca F. K. and Darkes J. Alcohol Expectancy Theory: The Application of Cognitive Neuroscience in K. E. Leonard and H. T. Blane, Psychological Theories of Drinking and Alcoholism, 1999, Guilford Press, USA, Chapter 6, p. 218.

Hilgard and Bower, 1975, p.599, in K. E. Leonard and H. T. Blane, Psychological Theories of Drinking and Alcoholism, 1999, Guilford Press, USA, Chapter 4, p. 107.

Lubman D. I.,Yücel M., & Pantelis C. Addiction, a condition of compulsive behaviour? Neuroimaging and neuropsychological evidence of inhibitory dysregulation. University of Melbourne, Victoria, 2004

Maisto S. A., Carey K. B. and Bradizza C. M., (1999) in in K. E. Leonard and H. T. Blane, Psychological Theories of Drinking and Alcoholism, 1999, Guilford Press, USA, Chapter 4, p. 113.

Marlatt and Gordon’s (1980, 1985), in S. Curry , G. A. Marlatt, and J. R. Gordon, Abstinence Violation Effect: Validation of an Attributional Construct With Smoking Cessation, Journal of Consulting and CK mcal Psychology, 1987, Vol. 55, No. 2, 145-149 University of Washington

Modell, J. G., Glaser, F. B., Cyr, L. & Mountz, J. M. (1992) Obsessive and compulsive characteristics of craving for alcohol in
alcohol abuse and dependence. Alcoholism: Clinical and Experimental Research, 16, 272–274.

Russell, 1976, in George F. Koob, Drug Addiction: The Yin and Yang of Hedonic Homeostasis, Neuron, Vol. 16, 893–896, May, 1996, Cell Press, Scripps Research Institute, Department of Neuropharmacology, La Jolla, California

Wise, (1998), in George F. Koob, Drug Addiction: The Yin and Yang of Hedonic